TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: 2^&,2.7 Date: 

Address: c33/ 8 Maf>le. '^ h 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC. Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

A Video of property (DVD): Pre-Stabilization & Post-Stabilization Videos 

\A Executive Summary 

A Signed Access Agreement Form 

A Advance Notice Form 

A Pre-Stabilization Video Agreement Form 

A Access Tracking Form 

y Property Access Assessment Form 

.A Neighbor Access Agreement Form 

\A Paint Match Form 

y Pre-Stabilization Property Safety Assessment Form 

A Work-Site Hazards Analysis Checklist 

A Photographs: Pre-Stabilization Property Hazard Assessment Photographs 

\A Douglas County Assessor Property information 

y Property Completion Agreement Form Signed by Property Owner 

y Property Close-Out Check List Signed By EPA 

Prudent Technologies, Inc. Signature

^jJ.yA ^ •^.s^.i.jJa.. ^

EPA Signature

30055310 

liHl 

Superfund 

 Date 

 Ih'^^Jc/O 

 Apite ^ 
TECHNOLOGIBS. INC. 

Property Summary 

Date: 11/~/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: Nov 

Property Address: 2518 Maple St. SAID #: 29827 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 9/17/2009 

ii. Work Began: 10/05/2009 

iii. Close-Out Date: 10/22/2009 

B. Enclosures: 

1. Pre-Stabilization Video 

2. Post-Stabilization Video 

3. Signed Access Agreement Form 

4. Advance-Notice Form 

5. Pre-Stabilization Video Agreement Form 

6. Access Tracking Form 

7. Property Access Assessment Form 

8. Neighbor Access Agreement Form 

9. Property Paint Match Form 

10. Pre-Stabilization Property Safety Assessment Form 

11. Work-Site Hazards Analysis Checklist 

12. Pre- Stabilization Property Hazard Assessment Photographs 

13. Douglas County Assessor Property Information 

14. Signed Property Completion Agreement Form 

15. Property Close-Out Check List Signed By EPA 
VR 

,lBS.TPiC. 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R7-08-07) with the U. S. Environmental Protection 

Agency (EPA) to stabilize Lead Based Paint (LBP) at a number of properties located in Omaha, Nebraska, including the 

property located at "T.^ ) 8" Tr)<ayli» S t" 

The EPA requests your permission to allow Prudent to perform LBP Stabilization at this property. By signing this form, the 

property owner grants permission to Prudent to perform activities related to LBP Stabilization including scraping paint and 

painting ofthe referenced property. Further, the owner/tenant verifies that they have received the LBP pamphlet "Renovate 

Right." 

By signing this document I agree to allow an EPA contractor to conduct a soil cleanup at my property following completion of 

lead-based paint stabilization, ifthe soil cleanup has not already been performed. I understand that the stabilization contractor 

cannot provide assurances of which contractor will be bound to the soil cleanup. I fiirther understand that the soil cleanup 

contractor will make all reasonable efforts to address concems that I, as the property owner, may have regarding soil 

cleanup at my property. 

[VI Yes, 1 have read and understand the paragraph above. 

Signature of Property Owner 

of/(7/o 7 

Date 

Ifyou have any questions about the LBP stabilization planned for your property, please contact Prudent's Customer 

Reiations/Office Manager for the Lead Based Paint Stabilization, Mrs. Shannon Holt, at (402) 504-1004 or (402)812-0223. 

General questions about the Omaha Lead Site cleanup can be directed to the EPA Public Information Centers at (402) 731­

3045 (South Omaha office) or (402) 991 -9583 (North Omaha office). 

Property Access Granted By: 

2^/g< l7f r $rr-hCt» n ( MOt^etj/ ^ ) 

(Please Print Name) 

Property Owner Signature: ;fe=^- ^ 

(Signature) 

0?//7/of 

(Date) 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TBOtn^OLOGIBS. IN C 

PROPERTY INFORMATION 

(To be completed by resident and/or property owner — please print) 

RESIOENTNAME: \ j (k( tX.lA'f Owner Renter 

RESIDENT ADDRESS: ^si8 r^o^\fi s t 

IF RENTAL, PROPERTY OWNED BY: 

^ 1 - H^-JJ^r f^yfTZ. 

OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER - HOME: (>//^l) ^yi'-L^VlyNORK : t^t H 1 ^^Z - 5^? ? 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: H ^ NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHOM PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: Ihe activities to be impiemented by EPA under this agreemenl arc 

pursuant to Seclion 104 ofCERCLA, 42 U.S.C. 9604. EPA's righl of access lo the property is provided for in Seclion 104(e) ofCERCLA, 

42 U.S. C 9605(e), which provides enu^ for "determining the need for response, or choosing or taking any response action under this lille. or 

otherwise enforcing the provisions ofthe title." 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, hiebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIES. INC. 

Advanced notice needed. 

After signing the access you allow Prudent to begin Lead Based 

Paint Stabilization. All Plants, weeds and any vehicles or items on 

open porch (enclosed porches will NOT be stabilized) must be 

removed prior to stabilization. All Pets must be out of yard during 

stabilization. How much notice do you need to have above 

mentioned tasks completed? Ifyou are a landlord you will need to 

contact the tenant as Prudent Technologies will only inform you. 

Do you have any pets that reside in yard? vy<ac-o*,\­

 (^woctf) Notice needed: . c y

Number to call to give notice: 5 7 ^ — -^S" z- 7 

Whom we are giving notice to: "^^a c • 

Home Owner's Signature 

.y<^ 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9688 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIES.] 

PRE-STABILIZATION VIDEO FORM 

1 UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL BE COMING 

OUT TO SHOOT A PRE-STABILIZATION VIDEO AT MY PROPERTY. 

THE VIDEO IS JUST A TOOL USED TO DOCUMENT THE CURRENT 

PROPERTY STATUS/CONDITION. A POST VIDEO WILL ALSO BE 

SHOT PRIOR TO COMPLETION OF STABILIZATION. 

OWNERS NAME: F*7«?Z-y 51 - HAj-J-^f' 

PROPERTY ADDRESS: 2 5 I ^ r^evpld S ^ 

BVID/SAID: Z ^ S* ^ 7 

HOMEOWNERS SIGNATURE: ^^ ^ 

^-^clet c S^f^.-vr^, tnan^^c ) 

PRUDENT REPRESENTATIVE SIGNATURE: ^ (>*•• — 

ANY CONDITION fEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (I.E. PETS, NOTICE NEEDED): 

^ y 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
"nEOINOLOGIBS,] 

ACCESS INFORMATION TRACKING SHEET 

BVID: Q,<^S2' ^ PROPERTY ADDRESS: '},S} ^ />ri(Xjpl'^ ^f~ 

Property Owned By: 

(If hew property owner) 

Owners Phone No's: Home: Work: 

Cell: Fax: ~ 

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACT DETAIL 

>^|/M^^ /gjfM iczr 

Comments: 

8080 Ward Parkway, Suite 405 2505 N. 24*" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax:(210)579-6577 
TECHNOLOGIES. 1 

Access Assessment Form: (Must be completed for every property. 

Information must be obtained from a property walk thru, not given 

by owner) 

Is the property stucco or asbestos? 

If yes, is any ofthe stucco or asbestos damaged or cracked? 

If yes, stop as we can't stabilize this property. It requires special preparation 

techniques. It will be returned to EPA and they will assign at a later date. 

Does this property require lots of scrapping? 

Does this property require a lift or scaffolding to reach upper levels? 

Does this property have lots of plants or items in areas where painting is 

required? 

Wo 

Does this property have any significant structural damage? 

If yes, EXPLAIN? 

8080 Ward Parkway, Suite 405 2505 N. 24*^ Street. Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIST 1 

Does this property have a garage? 

If yes, describe location of garage. 

Does this property have aluminum siding? 

If yes, is it original factory finish or has it been painted over? 

Does this property have any other type of structural components? (Le. roof 

shingles as siding)? 

j ^ o 

If yes, EXPLAIN? 

Is this property vacant or occupied? 

Are there any pets at this property? 

Are there any low hanging power lines? 

8080 Ward Parkway, Suite 405 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
OOLOGIES. INC. 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: 7.S ( 8" YO/^nU ^ ^ 

BVID: 2.*^S2,"7 

The following notes are for the benefit of paint crew only. 

Location 

Siding 

Soffit • 

Fascia 

Comer Trim 

Window Trims 

Door Trims 

Front Porch Ceiling 

Front Porch Ceiling Beams 

Front Porch Floor 

Front Porch Railings 

Front Porch Steps 

Siding Baseboards 

Foundation 

*?i?ac <;4-ep<; 4- \ 

H^ (p^C(^3c 

Paint Description 

rOflo) / \NOcA 

\fJoe<i -

Paint Yes 

•»«BRi>y 

y 

y 

Paint No 

oa ^ 

••• » 

>lfr 

y 

y 

Kf^ 

HPi 

wp 

y 

ooJ.;J-e2s^.'K'f>5C 

y 

V 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

4 

Homeowner signature: A r y ZSl Date: Aflf l lo f 

8080 Ward Parkway, Suite 405 2505 N. 24" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 679-6677 
TBCHNCaXXilES,] 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

1^0 

IF IT IS, GET ACCESS FROM ALL REQUIRED NEIGHBORHOOD PROPERTIES. 

8080 Ward Parkway, Suite 405 2505 N. 24*" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBSk] 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

2.5)9 yy)dipU s-f PROPERTY ADDRESS: 

BVID/SAID: ^ W O ^ T 

PRUDENT ASSESSMENT REPERSENTATIVE: 

^ M A^l ^ 

REPERSENTATIVE REMARKS/FINDINGS: 

(POWER-LINE PROXIMITY TO PROPERTY, SCAFFOLDING/ LADDERS/ LIFTS 

NEEDED, UNSAFE AREAS, UNSAFE NEIGHBORHOOD...ETC.) 

8080 Ward Parkway, Suite 405 2505 N. 24"" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIES. INC 

Checklist for the Worksite Hazard Analysis 

Address: ,^^1 ^ 

Crew: Date: 

L ^o^bi-^ 

::r^8 0 Ward ParkwayWSuite 405 2505 N. 24*" Street, Suite 308 4242 Medi ^ Drive, Suite 4250 

/-Kansas City, IVIO 6-1114 Omaha, Nebraska 68110 'n Antonio, TX 78229 -^ Phone: (816) 363-3703 Phone: (402)504-1004 Pfione: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 

Vii3i 

• ^ 

m i i-dii—ili f.. jm. 

^ ^ ' / / 

/

>:ss^ 

> 1 H

Douglas County Account Information Page 1 of2 

Douglas County, Nebraska Property Record - R2003450000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VJeW OH Ma p Infomiation is valid as of 2009-9-15 Treasurer's Tax Report 

New Feature • • r* T» Auto Sales Search 

Owner 

EL-HAJJAR FAYEZ 

ETAL h^'B ­ ^ )i 1 (. ^ 

11718 MEREDITH AVE 

OMAHA NE 68164-0000 .ji/Z_ A^ 

o^TT ~(/ Property Informatio n _ ^ -f^ .0­ ^ 

Key Number: 0345 OOOO 20 

Account Type: Residential 

Parcel Number: 2003450000 

Parcel Address: 2518 MAPLE gT 

OMAHA NE 68111-0000 

Legal Description: PATRICKS -A S- ADD LOT 5 BLOCK 8 W 30 FT 30 X 120 

Value Informatio n 

Land improvement Total 

2009 $1,900.00 $15,900.00 $17,800.00 

2008 $1,900.00 $17,400.00 $19,300.00 

2007 $1,900.00 $17,400.00 $19,300.00 

2006 $1,900.00 $17,400.00 $19,300.00 

2005 $1,900.00 $17,400.00 $19,300.00 

2004 $1,900.00 $9,200.00 $11,100.00 

Sales Informatio n 

Sales Date: 2003-09-25 

Deed Type: WD Book: 2003 Page: 196660 

Price: $20,000.00 

Grantor: JAMES HOLMON ETAL 

Grantee: FAVEZ EL-HAJJAR ETAL 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.08 3600.0 1.0 120.0 30.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2003450000 9/16/2009 
Douglas County Account Infonnation Page 2 of2 

2518 Maple 

Uir U I 

RANCH 

isTSJs^.n. 

Mjr it a 

!mMCLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 1075.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Poor 

Built As: 1 1/2 Story Unfin Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 5.0 

Exterior: Frame Siding Units: 1.0 

Interior Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Buiit Physical Age 

1885 0% 1885 124 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 901.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Porch Slab Roof Ceil 172.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2003450000 9/16/2009 
40L0GIBS.INC. 

2. TO BE FILLED OUT ONLY IF CHANGING COLOR 

PROPERTY ADDRESS: 

BVID: 

Location Paint Description 

Paint 

Yes 

Paint 

No 

Siding 

Soffit 

Fascia 

Comer Trim 

Window Trims 

Door Trims 

Front Porch Ceiling 

Front Porch Ceiling Beams 

Front Porch Floor 

Front Porch Railings 

Front Porch Steps 

Siding Baseboards 

Foundation 

1 AGREE TO THE COLORS INDICATED ABOVE. I UNDERSTANT THAT I 

CANNOT CHANGE THE SELECTED COLORS LATER ON AS PRUDENT 

WOULD HAVE PURCHASED THE PAINT SPECIFICALLY FOR THE 

REFERENCED PROPERTY. ALSO I UNDERSTAND THAT COLORS SELECTED 

MAY NOT LOOK. EXACTLY AS IT IS SHOWN ON SWATCHES AFTER 

PAINTING ON MY PROPERTY. 

Homeowner signature: Date: 

8080 Ward Parlcway, Suite 405 2506 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4260 

Kansas city, MO 64114 Omaha, Nebraska 68110 San Antonio. TX 78229 

Phone:(816)363-3703 

Fax: (816) 363-3707 

Phone: (402)504-1004 

Fax: (402)504-1005 

Phone: (210)822-9688 

Fax: (210) 679-6677 
40L0GIBS. INC. 

2. TO BE FILLED OUT ONLY IF CHANGING COLOR 

PROPERTY ADDRESS: £1 $ 1 Y n C^P I 

BVID: MU y 

Location 

Siding 

Soffit 

Fascia 

Comer Trim 

Window Trims 

Door Trims 

Front Porch Ceiling 

Front Porch Ceiling Beams 

Paint Description 

6-r< ^ 

^ 

V>^:)V\V 

vQ w ; V^ 

O w~^^­

<-o v;v 

^O W\ lr 

N/A 

Paint 

Yes 

y 

t / 

v / 

^ 

Paint 

No 

Front Porch Floor 

Front Porch Railings 

Front Porch Steps 

Siding Baseboards 

Foundation IA3 W\ ^ ^ 

I AGREE TO THE COLORS INDICATED ABOVE. I UNDERSTANT THAT I 

CANNOT CHANGE THE SELECTED COLORS LATER ON AS PRUDENT 

WOULD HAVE PURCHASED THE PAINT SPECIFICALLY FOR THE 

REFERENCED PROPERTY. ALSO I UNDERSTAND THAT COLORS SELECTED 

MAY NOT LOOK EXACTLY AS IT IS SHOWN ON SWATCHES AFTER 

PAINTING ON MY PROPERTY. 

Homeowner signatiire^^,,^^^^ Date: f^<{\uglo ^ 

8080 Ward Parlcway, Suite 405 2505 N. 24*" Street, Suite 308 4242 (Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

p ^ I have receiveci a copy of the pamphlet, Renovate Right: important Lead Hazard 

' Information for Families, Child Care Providers and Schools informing me of 

the potential risk of the lead hazard exposure from renovation activity to be 

performed in my dwelling unit. 1 received this pamphlet before the work began. 

Printed name of recipient Date 

yy^ir ^ c 

bignature of recipient 

Self-Certification Option (for tenant-occupied dwellings only) — 

If the lead pamphlet was delivered but a tenant signature was not obtainable, 

you may check the appropriate box below. 

• Refusal to sign — I certify that I have made a good faith effort to deliver the 

pamphlet. Renovate Right: Important Lead Hazard Information for Families, 

Child Care Providers and Schools, to the rental dwelling unit listed below at the 

date and time indicated and that the occupant refused to sign the confirmation 

of receipt. I further certify that I have left a copy of the pamphlet at the unit with 

thepccupant. 

ijM^available for signature — I certify that I have made a good faith effort to 

deliver the pamphlet, Renovafe Right: Important Lead Hazard Information for 

Families, Child Care providers and Schools, to the rental dwelling unit listed 

below and that the occupant was unavailable to sign the confirmation of receipt. 

I further certify that I have left a copy of the pamphlet at the unit by sliding it 

under the door. 

Printed name of person certifying /) Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person certifying lead pamphlet delivery 

Unit Address 

Note Regarding Mailing Option — As an alternative to delivery in person, you 

may mail the lead pamphlet to the owner and/or tenant. Pamphlet must be mailed 

at least 7 days before renovation (Document with a certificate of mailing from the 

post office). 
TECEflNOLOGEBS. INC. 

Prudent Property Ciose-Out Form (Lead-Based Paint Stabiiization) 

SAID: A^g2 1 :. 

Property Address: c^S^g . MdPJg . ^ X 

Owner's Name: x^ jonc i ^CY^WC*' ^ 

S.NO 

Performance Standards/close-Out Criteria Yes NO 

1 

Was the entire structure(s) painted with the exception of the stated, 

excluded areas? This would include painting of other associated 

features including fascia, eaves, siding, all trim, porches, box 

\ ^ beams, columns, rails, and exterior surfaces of garages. 

2 Was all scraping and other preparation work completed 

satisfactorily? \y ^ 

3 Were ali required areas of the structure(s) primed as needed and 

• ^ painted with two top coats? 

4 Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? ^ 

5 Did the contractor collect/vacuum all falling and scraped paint chips 

on the entire property, roadways, alleyways, public access areas 

^ 

and also remove any other generated debris? 

6 Is the grass area that surrounds the structure(s) in reasonably good 

.y condition? 

7 Was the paint products utilized equivalent to a 30 year 

^

product/quality? 

8 Are all items such as polyethylene sheeting, ladders, paint brushes, 

^ 

cones, barrier tape etc properiy, removed? 

9 Is there any evidence of property damage that was done by the 

contractor? Any property damage needs to be completed prior to 

^ the EPA Close-OuL 

10 Are there any property items that were temporarily re-located by the 

\ ^ contractor that need to be moved back? 

11 Are there any (known) lingering issues with the property owner(s) 

that have been left unresolved? V-/ 

12 Other Considerations? Property Owner Discussions? Additional 

Wor u / k that is Required 

Prudent Representative Signature: 

Date: 

Property Owner Signature: .'-y' 

Date: lo/p-j^ ^ 

8080 Ward Parlcway, Suite 405 2505 N. 24*" Street. Suite 308 4242 Medical Drive. SuitB 42S0 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio. TX 78229 

Phone: (816) 363-3703 Plione: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOIJOGnSl INC. 

EPA Ciose-Out Form (Lead-Based Paint Stabilization) 

BVID: ^^^X ^ 

Property Address: i p o I oi PMotpU ^ hOwner's Name: F^V^ ^ '^ ^ WAJJ^CJU 

Performance Standards/close-Out Criteria 

Was the entire structure(s) painted with the exception of the stated, 

excluded areas? This would include painting of other associated 

features including fascia, eaves, siding, all trim, porches, box 

beams, columns, rails, and exterior surfaces of garages. 

Was all scraping and other preparation work completed 

satisfactorily? 

Were all required areas of the structure(s) primed as needed and 

painted with two top coats? 

Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

Did the contractor collect/vacuum all falling and scraped paint chips 

on the entire property, roadways, alleyways, public access areas 

and also remove any other generated debris? 

Is the grass area that surrounds the structure(s) in reasonably good 

condition? 

Was the paint products utilized equivalent to a 30 year 

product/quality? 

Are all items such as polyethylene sheeting, ladders, paint brushes, 

cones, barrier tape etc properiy removed? 

Is there any evidence of property damage that was done by the 

contractor? Any property damage needs to be completed prior to 

the EPA Close-Out. 

Are there any property items that were temporarily re-located by the 

contractor that need to be moved back? 

Are there any (known) lingering issues with the property owner(s) 

that have been left unresolved? 

Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

S.NO 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

Yes 

y 

y 

A 

/ 

/ 

/ 

y 

A 

NO 

A 

A 

/ 

/ 

EPA COR/ Representative Signature. 

Date: lljiU/o1